Those who failed Sarah Reed must be held to account

There were from time to time gasps, cries and exclamations coming from the public, the family and the jury as we sat through Sarah Reed’s inquest at the City Of London coroner’s court, which ended last week.

Sarah died on 11 January 2016 while on remand at Holloway women’s prison, London. She was on the medical wing of the prison and was reportedly found, at around 8am, lying on her prison bed. The crown asserted, and the jury agreed, that Sarah had killed herself through “self-strangulation”.

Sarah suffered acute mental ill health, triggered by the sudden death of her baby daughter in 2003. Sarah and her partner struggled to cope after they were told to take their deceased baby in a taxi from a children’s hospice to their home to find an undertaker.

It was at this point that Sarah began her slow decline into mental ill health. Prior to this she was an intelligent, loving daughter and mother with her whole life ahead of her. But she became haunted by the vision of her deceased child. In retrospect, it seems now beyond any reasonable understanding that a child’s hospice (now closed) could behave in such a callous manner.

The inquest has been a deeply traumatic experience for the family, having to endure a detailed commentary of the last days and minutes of Sarah’s life while in Holloway.

The jury found that Sarah took her own life and, in a damning narrative verdict, went on to castigate the prison staff and mental health professionals for a series of abject failures – including failing to follow Ministry of Justice guidelines – that contributed to her death.

Sarah faced everyday racism as a black woman; she was also violently beaten by a Metropolitan police officer in 2012. The assault was so vicious that Sarah suffered two broken ribs. The officer, PC James Kiddie, was subsequently found guilty of assault, given a community service order and sacked from the force.

The convergence and intersectionality of Sarah’s race, gender and mental health vulnerability combined in a vortex of race discrimination and institutional indifference. In late 2015, while in a secure mental health ward, Sarah claimed that an elderly male patient tried to sexually assault her. She defended herself, was restrained and subsequently arrested, and on 14 October was placed on remand, at the direction of the magistrate, solely for the purposes of obtaining psychiatric reports assessing her fitness to plead.

The jury heard that Holloway prison received the request for these reports on 27 October 2015. Unbelievably, these reports were not completed before her death nearly three months later.

This monumental failure, to undertake a psychiatric assessment of her fitness to stand trial, led the jury to find that “the failure to conclude the fitness to plead assessment in a timely manner contributed to her subsequent death”.

Sarah had her antipsychotic medications reduced on 16 November 2015 after concern about its effect on her respiratory system. Sarah’s psychotic symptoms progressively worsened as a result, yet alternative treatments that would not affect her respiratory systems were not prescribed for her.

Sarah was left in an increasingly distressed state, chanting religious parables incessantly, staring blankly at her cell wall and reporting she was being repeatedly punched by demons as she slept. For the last three days of her life, she remained locked in her cell, alone and isolated, with a hospital screen around her hatch.

The jury heard the segregation unit, where Sarah was isolated for “bad behaviour”, was often freezing cold and without any hot water or heating. Every prison infraction Sarah made was dealt with by way of punishment.

At 5ft 7in (1.7m) and weighing only eight stone (51kg), Sarah was designated so dangerous as to require four prison officers to unlock her door every time someone went in or out of the cell. This is usually reserved for only the most dangerous of prisoners. Throughout this period, the prison cancelled visits to Holloway by Sarah’s mother, her partner and her solicitors on 11 separate occasions.

Sarah’s death was entirely avoidable. She would be alive now if the governor, prison staff, psychiatrists and mental health in-house team had simply done their jobs in a timely and professional manner. For Sarah’s family, the inquest verdict is not the end. They are demanding that all the agencies and professionals whose failures contributed to her death should be subject to immediate disciplinary investigations. All must be held to account if we are to end the scandal of the treatment of the mentally ill and vulnerable in our prisons.

In addition, the Reed family will now campaign for all coroners’ recommendations to be considered mandatory. Had previous inquest recommendations been implemented in historical cases such as that of Rocky Bennett – in which the coroner called for a national director for mental health and ethnicity – or the Corston report on managing mentally ill women in prison, many lives could have been saved. Further, home secretary Amber Rudd’s much-delayed report into “deaths in police custody” must now be published.

The catastrophic failure of successive governments to implement these critical recommendations is obscene: the tragedies that inform them may have been forgotten, but the invaluable lessons learned cannot be ignored.